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Pelvic exenteration

Pelvic exenteration is the most extensive pelvic surgery. It’s used most often when cancer of the cervix has recurred (come back) in the pelvis after surgery or radiation therapy. In this surgery, the uterus, cervix, ovaries, fallopian tubes, vagina, and sometimes the bladder, urethra, and/or rectum are removed. If two ostomies are created, this surgery is called a total pelvic exenteration; one ostomy is for urine and the other is for stool. The vagina is usually rebuilt. Lymphedema may be a problem after surgery. (See “Surgery for cancer of the vulva (vulvectomy),” above). Because pelvic exenteration is such a major surgery, some cancer centers offer counseling sessions before surgery to help the woman prepare for the changes in her body and her life.

Recovery from pelvic exenteration takes a long time. Most women don’t begin to feel totally healed for up to 6 months after surgery. Some say it takes at least a year or 2 to fully adjust to the changes in their bodies. A recent prospective study of women undergoing pelvic exenteration supports this notion. This study found that quality of life declined right after surgery, but longer follow up (12 months later) showed that many women physically and emotionally adjusted well over time, with improvement in body image and overall quality of life.

If a woman has pelvic exenteration surgery, it doesn’t mean that she can’t lead a happy and productive life. With practice and determination, some women who have had this procedure can again have sexual desire, pleasure, and orgasm. Usually the outer genitals, including the clitoris, are not removed, which means a woman may still feel pleasure when touched in this area.

Vaginal reconstruction after total pelvic exenteration

If all or most of the vagina must be removed, it’s possible to build a vagina with tissue from another part of the body. A neovagina (new vagina) can be surgically created out of skin, or by using both muscle and skin grafts. This new vagina can allow a woman to have intercourse.

Skin grafts: When the vagina is repaired with skin grafts, the woman must use a vaginal stent. This stent is a special form or mold worn inside the vagina to keep it stretched. At first, the stent must be worn all the time. Then it’s worn for most of each day for many months after surgery. After about 3 months, regular vaginal penetration during sexual activity or the use of a plastic tube or dilator to stretch out the vagina for a few minutes each day can help to keep the vagina open. Without frequent stretching, the neovagina may shrink, scar, or close.

Muscle flaps and skin grafts: There are other ways to rebuild the vagina using muscle tissue and skin from other parts of the body. One way is to use flaps of muscle and skin from the lower chest and belly (abdomen). This method is called a VRAM (vertical rectus abdominis muscle) flap, and over the past few years it has been shown to work very well. The blood vessels and nerves for this tissue stay attached to their original site. This means that the neovagina may have more sensation and stay open more easily. The surgeon forms the flaps into a closed tube, which is lined by the skin surface. It’s then sewn into the area where the vagina has been removed. Part of the muscle is used to fill in the space in the pelvis where organs have been removed. When the neovagina heals, it is much like the original in size and shape, but it will not feel or function the same. Still, different can be OK. An older, less-used method takes skin and muscle from both inner thighs. Other graft sites can also be used.

A vagina that is rebuilt with muscle flaps and skin makes little or no natural lubricant when a woman becomes excited. A woman will need to prepare for intercourse by spreading a gel inside the vagina. If hair was present on the skin where the graft came from, she may still have a little hair inside the vagina. During sexual activity with a rebuilt vagina, a woman may feel as if the area the skin came from is being stroked. This is because the walls of the vagina are still attached to their original nerve supply. Over time, these feelings become less distracting. They can even become sexually stimulating.

Care of the rebuilt vagina: A natural vagina has its own cleansing system. Fluids drain out, along with any dead cells. The rebuilt vagina cannot do this and needs to be cleaned with a douche to prevent discharge and odor. A doctor or nurse can offer advice on how often to douche and what type to use.

Women also notice that the muscles around the vaginal entrance cannot be squeezed together. A woman may miss being able to tighten her vagina. After the vagina is rebuilt, partners need to try different positions to find one that is best. Minor bleeding or “spotting” after penetration is not a cause for alarm, but heavy or increased bleeding should be discussed with a doctor.

Orgasm after total pelvic exenteration

With pelvic exenteration, all or part of the vagina may be removed, which can affect the nerves that supply the clitoris. Still, some women are able to have orgasms after this type of surgery, though it takes practice and persistence.

Since the exact surgical procedure can vary from one person to another, it may help to speak with your surgeon about the full extent of the surgery before you have it. Ask what you can expect in the way of sexual function, including orgasm, after surgery.